Provider Demographics
NPI:1023034055
Name:SIMMONS, LARRY DEAN (DDS, PA)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:DEAN
Last Name:SIMMONS
Suffix:
Gender:M
Credentials:DDS, PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1007 ROCKFORD ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:MOUNT AIRY
Mailing Address - State:NC
Mailing Address - Zip Code:27030-5325
Mailing Address - Country:US
Mailing Address - Phone:336-789-2075
Mailing Address - Fax:336-789-2041
Practice Address - Street 1:1007 ROCKFORD ST
Practice Address - Street 2:SUITE 1
Practice Address - City:MOUNT AIRY
Practice Address - State:NC
Practice Address - Zip Code:27030-5325
Practice Address - Country:US
Practice Address - Phone:336-789-2075
Practice Address - Fax:336-789-2041
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4115122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8997831Medicaid